Massive Transfusion Protocol

Reviewed and revised 10 March 2014

OVERVIEW

Massive transfusion is defined as

• replacement of >1 blood volume in 24 hours, or
• >50% of blood volume in 4 hours (adult blood volume is approximately 70 mL/kg), or
• in children:  transfusion of >40 mL/kg (blood volume in children over 1 month old is approximately 80 mL/kg)

A Massive Transfusion Protocol should be used in critically bleeding patients anticipated to require massive transfusion

GOALS IN MANAGEMENT OF MASSIVE TRANSFUSION

• early recognition of blood loss
• maintenance of tissue perfusion and oxygenation by restoration of blood volume and haemoglobin (Hb)
• arrest of bleeding in combination with use of early surgical or radiological intervention, and
• judicious use of blood component therapy to correct coagulopathy

THERAPY INDICATIONS IN MASSIVE TRANSFUSION

• Check these parameters early and frequently (e.g. every 30-60 minutes while massive transfusion is ongoing)

Parameters	Values to aim for
Temperature	>35 °C
Acid-base status	pH >7.2, base excess <–6, lactate <4 mmol/L
Ionised calcium (Ca)	>1.1 mmol/L
Haemoglobin (Hb)	This should not be used alone as transfusion trigger; and, should be interpreted in context with haemodynamic status, organ & tissue perfusion.
Platelet (Plt)	≥ 50 x 10^9 /L (>100 x 10^9 if head injury/ intracranial haemorrhage)
PT/APTT	≤ 1.5x of normal
Fibrinogen	≥ 1.0 g/L

MASSIVE TRANSFUSION PROTOCOL TEMPLATE

• See Massive transfusion protocol template

PROBLEMS WITH MASSIVE TRANSFUSION

Risks and complications of large volume resuscitation with blood products

• volume overload (careful monitoring of filling pressures, response to volume, diuresis etc)
• over-transfusion (monitor Hb regularly, titrate according to needs)
• hypothermia (monitor temp, use fluid warmers and other measures to reduce heat loss)
• dilutional coagulopathy of clotting factors and platelets (regular and early monitoring of coagulation, involvement of haematology for replacement therapy )
• Transfusion related acute lung injury (consider use of filters, leukodepletion)
• excessive citrate causing metabolic alkalosis and hypocalcaemia (monitor pH and ionised calcium, replace calcium as necessary)
• hyperkalaemia (use of younger blood, monitor regularly, may require specific therapy)
• disease transmission (use of products only on a needed basis only, standard blood banking precautions etc)

If uncross-matched / O neg blood

• Haemolytic disease of newborn if RhD mismatch
• Difficulty with cross-matching future blood product
• Difficulty with matching solid organs

Logistical issues

• distractions resulting in not controlling source of haemorrhage, and
• risks of hurried cross-checking and incompatibility (allocation of sufficient resources and personnel, standard programs in place to facilitate process and anticipate needs)
• other problems including loss of identity, crossmatching issues, loss of baseline haematological information etc)

Usual transfusion reactions and problems

• TRALI / TACO
• Acute / delayed haemolytic transfusion reaction
• Non-febrile haemolytic transfusion reaction
• Bacterial / viral infection
• Anaphylaxis if IgA deficient
• GVHD
• Storage lesion effects

References and Links

References

• National Blood Authority. Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion.[cited 2011 Jun 30]. Available from: http://www.nba.gov.au.

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